The programme for the prevention and control of diabetes during pregnancy has suffered a setback in Uttar Pradesh because the government has been unable to finalise, for months, a tender for 75gm glucose pouches that a previous vendor was supplying for Rs 9.9 each, a person associated with it said. This not only puts at risk the lives of expectant mothers with diabetes and their babies, but they are also likely to develop health complications later in life. We spoke to Usha Gangwar, general manager (Maternal Health), National Health Mission, UP, and sent her email queries on September 17, but got no response despite reminders.
Recognising that gestational diabetes mellitus (GDM) is a risk factor, universal screening for it was made part of the NHM. In 2014, the government issued technical and operational guidelines. These required pregnant women to be administered oral glucose tolerance test (OGTT) at their first contact with a primary health centre, a community health centre or a district hospital. They were to be given 75gm of glucose dissolved in 300ml of water, and after two hours their blood sugar level was to be gauged. If it was at or above 140mg/dl of blood, they were to be diagnosed as having GDM. If not, the test was to be repeated between the 24th and 28th week of pregnancy. (Since placental hormones stimulate insulin resistance as pregnancy advances, the test cannot be done too early. If done too late, after 28 weeks, harm would have been done to the foetus). Those with GDM were required to exercise and put on a diet that would bring blood sugar levels down to normal within two weeks, while meeting their requirement of energy and body weight (300-400gm per week, up to 10-12kg during pregnancy). If this did not do the trick, they were to be put on metformin, a drug, or insulin.
The threshold level above which blood sugar levels are considered abnormal is lower in pregnancy. Men and non-expectant women are regarded as having diabetes if their blood glucose level is above 199mg/dl. If it is in the 139-199mg/dl range, they are in the pre-diabetes stage. Pregnant women are considered pre-diabetic or having gestational glucose intolerance (GGI) if their blood sugar level is between 119mg/dl and 139mg/dl.
Chennai-based V Seshiah, who was a member of the expert group that wrote the GDM guidelines for NHM, says the foetus' renal glucose threshold level is 110mg/dl. So a mother's post-meal blood glucose levels should be in the 110-120mg/dl range.
GDM poses higher risk of babies dying in womb in the 28th week of pregnancy or after (stillbirth). It aggravates chances of a newborn dying within 28 days or birth (neonatal death). In a 2018 study, doctors found that of 12,784 pregnancies with GDM in UP, 406 (3.17%) had ended in stillbirths. In another 191 (1.49%) cases, babies had died within 28 days of birth. For comparison, another group of 7,287 pregnant women who did not have GDM were studied. They had a much lower incidence of stillbirths and neonatal deaths: 92 and 47, respectively. The study was done between October 2014 and September 2016 in districts covered by the gestational diabetes prevention and control project. In all, 5,15,532 pregnant women were given OGTT at 828 healthcare centres between 16th and 20th week of pregnancy. If tested negative, they were tested again between the 24th and 28th week.
Rajesh Jain, the manager of the project, conducted the study with three doctors. Jain is also the president of the Implementation Committee of the Diabetes in Pregnancy Study Group India (DIPSI), whose recommendations form the basis for the national GDM screening guidelines.
India has a high prevalence of GDM. A study (between January and December 2016) by Prof Vinita Das and three of her colleagues at the department of gynaecology and obstetrics, King George's Medical University (KGMU) at the Queen Mary's Hospital in Lucknow, found a GDM prevalence rate of 13.9%. In all, 5,855 pregnant women who reported at the hospital's ante-natal outpatient department were given OGTT as per national guidelines.
In another study of 57,018 pregnant women between October 2012 and September 2014 in Kanpur Nagar district, a similar GDM prevalence rate was found. Of the women tested, 7,641 (13.4%) were found to have GDM. The rate was higher in urban areas (16%), lower in rural (9.8%).
Nationally, the GDM prevalence rate is estimated at 10-14%, says Dinesh Baswal, deputy commissioner (Maternal Health) in the health ministry.
Diabetes and impaired glucose intolerance is more prevalent among pregnant women than among people in general. A population-based study of 14 states and one UT (Chandigarh) published in 2017 noted the prevalence of diabetes at 7.3%-varying from 4.3% in Bihar to 10% in Punjab. People in urban areas were more at risk. The prevalence of pre-diabetes was 10.3%-ranging from 6% in Mizoram to 14.7% in Tripura. The results of the survey in UP, Delhi, Madhya Pradesh and a few other states will be published next year. It is being conducted by the ICMR and the INdia DIABetes study group.
Indian women have a 11-fold risk of developing glucose intolerance during pregnancy compared to Caucasians, says SV Madhu of University College of Medical Sciences at GTB Hospital, Delhi, in an article in an Indian diabetes journal. Complications for mother include greater need for C-section. It can cause large babies and congenital malformations in them. Women with GDM have a seven-fold risk of developing Type-2 diabetes. This risk increases steeply five years after delivery. They also have a higher prevalence of metabolic syndrome and increased risk of cardiovascular diseases. Children of GDM mothers have a higher risk of obesity and diabetes. About one-third of children born of diabetic pregnancies develop glucose intolerance before the age of 17.
"You are what your mother ate," says Seshiah. "It's nearly impossible to do anything about diseases that have a foetal origin." The focus should on "primordial prevention." Risk factors that cause diabetes should be tackled early so that there is no need for treatment that is "horribly expensive." Seshiah believes "the government is not beating the drumbeat (sic) properly" on diabetes. On HIV and TB, it has done a far better job of creating awareness. This is the reason why universal screening for diabetes in the target groups is still patchy.
According to Baswal, six states-UP, Delhi, Bihar, MP, Odisha and Tamil Nadu-have sought funds for GDM screening from the Centre. He was unable to say whether all of them have rolled out GDM screening and, if so, how many of their districts have been covered. In UP, which has high infant and maternal mortality rates, 36 of 75 districts are covered by the GDM prevention and control project, which requires universal screening of pregnant women. In another 14 districts, public healthcare professionals-doctors, nurses, auxiliary nurse midwives-are being trained. The state's healthcare spending is low, but it compares with that of other states. At 4.8% of aggregate government expenditure, it is aligned to the national average. But it is the quality of spending that matters. Tamil Nadu's share is 4.5%, but it has a very good public healthcare system and an efficient centralised medical supplies procurement mechanism. UP should do a much better job of screening. A lot of pregnant women at risk of diabetes are slipping through the cracks at a huge cost to themselves and the state. The inability of the state to ensure uninterrupted supplies of glucose pouches is a poor comment on its sense of responsibility.
The author blogs at smartindianagriculture.com